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Abstract

Background

During the 90s, Greece has been transformed to a host country for immigrants mostly
from the Balkans and Eastern European Countries, who currently constitute approximately
9% of the total population. Despite the increasing number of the immigrants, little
is known about their health status and their accessibility to healthcare services.
This study aimed to explore the perceived barriers to access and utilization of healthcare
services by immigrants in Greece.

Methods

A pilot cross-sectional study was conducted from January to April 2012 in Athens,
Greece. The study population consisted of 191 immigrants who were living in Greece
for less than 10 years. We developed a questionnaire that included information about
sociodemographic characteristics, health status, public health services knowledge
and utilization and difficulties in health services access. Statistical analysis included
Pearson’s ×2 test, ×2 test for trend, Student’s t-test, analysis of variance and Pearson’s correlation
coefficient.

Results

Only 20.4% of the participants reported that they had a good/very good degree of knowledge
about public health services in Greece. A considerable percentage (62.3%) of the participants
needed at least once to use health services but they could not afford it, during the
last year, while 49.7% used public health services in the last 12 months in Greece.
Among the most important problems were long waiting times in hospitals, difficulties
in communication with health professionals and high cost of health care. Increased
ability to speak Greek was associated with increased health services knowledge (p<0.001).
Increased family monthly income was also associated with less difficulties in accessing
health services (p<0.001).

Conclusions

The empowerment and facilitation of health care access for immigrants in Greece is
necessary. Depending on the needs of the migrant population, simple measures such
as comprehensive information regarding the available health services and the terms
for accessibility is an important step towards enabling better access to needed services.

Keywords:

Access; Greece; Immigrants; Knowledge; Public health services

Background

According to the WHO European Region Health 2020 policy framework [1], successful governments may achieve real improvements in health if they work across
government to improve health for all and reduce health inequalities. Many groups,
with immigrants being one of them, have been left behind and, in many instances, as
economies falter, health inequalities are growing within and between countries. Access
for all, to high-quality and affordable care is considered one of the milestones towards
an equitable, sustainable and of high quality health system.

Greece has been traditionally a country which sent immigrants to rapidly developing
countries. However, since the early ‘90s it has transformed into a country which hosts
immigrants, mainly from the Balkans [2]. In 2009, 958.000 immigrants (both documented and undocumented) were estimated to
be living in Greece comprising 9% of the population [3]. Most of the immigrants are coming from Albania (58%) and countries from Eastern
Europe (Ukraine, Moldavia, Georgia etc.) at a percentage of (14%) while immigrants
from Asia and Africa are estimated to be 10% of migrant population.

Evidence shows that immigrants are more vulnerable to social and economic disadvantage,
something that affects health outcomes as well as access to health care [4,5]. In particular, social exclusion is closely linked to migration [6]. Socially excluded are defined by the same authors, as those who are marginalised
and stigmatised due to their distinguishing characteristics (e.g. low paid wages).
These groups are more likely to be excluded from a number of social and community
life aspects such as participation in civil society, lack of or inadequate provision
of social goods (e.g. language services), education and healthcare, and exclusion
from social production and consumption. As far as healthcare is concerned, immigrants
usually face obstacles and difficulties in accessing the health services of the country
of their residence as well as the quality of any services provided. European Union
authorities have pinpointed the specific problem and have stressed the need for application
of national policies for tackling it [7].

The health care system in Greece is linked to employment status and type of employment.
The newly created National Health Services Organization was intended to cover the
vast majority (more than 95%) of the population (workforce, dependents and pensioners),
assuming the presence of only short-term unemployment. The basis for entitlement is
insurance status. Regarding entitlement of migrants to health services, as stated
in a study [8] conducted for the policies on health care for migrants in EU 27 “migrants legally
residing in the country enjoy the same rights as citizens in terms of access to the
healthcare system. The requirement however is to have insurance, as they cannot claim
the welfare benefit, nor the card which allows persons with low income free access
to healthcare. Free (or subsidized) healthcare is strictly connected to affiliation
to a social insurance. Only legal aliens, namely those holding a residence and employment
permit, have a right to social insurance”.

However, in the context of the deep crisis, unemployment rose rapidly since 2009 to
reach 26.8% in January 2013. Under pre-existing legislation, EOPYY only effectively
covers the unemployed for a maximum of two years, thus leading to a rise in the percentage
of the uninsured population and migrants, as a vulnerable group, are mostly affected
by that economic turmoil.

Even though scientists and health policies are continually dealing with the issue
of inequalities in health care [9,10] there is not clear evidence about the health status of the approximately one million
immigrants living in Greece today and their accessibility to healthcare services.
Although immigrants are considered as a high risk group, vulnerable to poverty and
social exclusion, there is a lack of an in-depth analysis and documentation of the
factors that lead to this situation.

Until today, there hasn’t been a formed policy regarding the access and use of health
care services mainly due to a lack of sound data for the epidemiological profile of
immigrants and the use of health services by them. Therefore the development of any
health care policy for immigrants must be evidence-based on health care needs of immigrants.
Additionally, information is needed regarding the extent that the immigrants have
access in health services and if that access is of satisfactory quality. Inevitably
studies regarding the health literacy and use of health care services are essential.

This study aimed to explore the perceived barriers to access and utilization of healthcare
services by immigrants in Greece. The present project aims to fill a gap by investigating
the perceptions of immigrants from developing countries on barriers to healthcare
access in Greece and proceed to specific proposals regarding the best ways to enhance
the access of these groups in health care services.

Methods

Study population

A cross-sectional study was conducted from January to April 2012 in Athens, Greece.
The study population consisted of 191 immigrants who were living in Greece less than
10 years. Although there is not a universally accepted definition of immigrant the
term in the present study, is based on the definition as it is published in the Glossary
of Migration [11] and it applies to persons, and family members, moving to another country or region
to better their material or social conditions and improve the prospect for themselves
or their family.

The participants reported being documented migrants. However, the investigators were
not able to verify this information since immigrants often are reluctant or afraid
to state differently. Regarding the sampling method, there is no accurate census of
immigrants in Greece since, members of some immigrant populations, such as Pakistani
and Indian for example, are extremely difficult to locate. Thus, probability or random
sampling could not be realized and therefore snowball sampling (a non-probability
sampling method) was applied. Country of origin of immigrants was Albania, Georgia,
Afghanistan, Philippines, Russia, Bulgaria, Nigeria and Ghana. Initially, we contacted
key persons in immigrant communities, such as their leaders or representatives. Those
key persons acted as mediators between investigators and immigrants in order to increase
feelings of trust and comfortability. Immigrants with a good level of Greek language
proficiency facilitated the procedure of interviewing as translators. A workshop took
place in order to inform the translators about the objectives of the study and to
train them on the content of the questionnaire and the interviewing procedure. Face-to-face
interviews were conducted with immigrants with a mean duration of 30 min in their
native language. During the whole procedure both the investigators and the translators
were present in order to ease the completion of the interviews. Through the abovementioned
research design a high response rate (91%) was achieved. A little more than half of
the participants (51.3%) were interviewed in their language, while 36.7% of the interviews
were conducted in Greek and 12% in English. Participants were informed about the study
and gave their written consent. Personal data of immigrants were not registered at
any stage of the study. The study protocol was approved by the ethics committee of
the Faculty of Nursing of the University of Athens.

Measures

A questionnaire was developed including information on sociodemographic characteristics,
health status, public health services knowledge and utilization and perception of
difficulties in health services access. A qualitative study [12] was conducted prior to this one, in order to construct the quantitative questionnaire
of our study. A pilot quantitative study with 30 immigrants was carried out, in order
to improve the comprehensibility of the questionnaire. Internal consistency of the
questionnaire was calculated by Cronbach’s alpha and was found equal to 0.7 which
was considered acceptable.

Sociodemographic characteristics included age, country of origin, months of stay in
Greece, gender, marital status, number of children, educational level (less than high
school, high school, at least some college), smoking habits (smokers and non-smokers),
health insurance coverage, employment at the time of study, family monthly income
and living arrangement. Also, we measured immigrants’ ability to understand, speak,
read and write in Greek in a five-point Likert-type scale (very poor, poor, moderate,
good and very good).

Public health services knowledge was measured on a five-point Likert-type scale (very
poor, poor, moderate, good and very good). For statistical analysis purposes, very
poor and poor knowledge considered to be one category and also good and very good
knowledge considered to be one category.

Public health services utilization included physician visits, dentist visits, use
of emergency department services and inpatient hospital care. For physician and dentist
visits, number of visits during the past 12 months was asked. For use of emergency
department services and inpatient hospital care, the immigrants were asked whether
they had been admitted in an emergency department or hospital within the preceding
12 months.

Difficulties in public health services access was measured on a five-point Likert-type
scale (not at all, slightly, moderately, quite a bit and extremely difficult). For
statistical analysis purposes, not at all and slightly difficult considered as one
category and quite a bit and extremely difficult considered being one category also.

Statistical analysis

The normality assumption was evaluated using Kolmogorov-Smirnov criterion (p>0.05
for all variables), histograms and normal probability plots. The continuous variables
appeared reasonably normally distributed. Continuous variables are presented as mean
(standard deviation, SD), while categorical variables are presented as absolute and
relative frequencies. To determine associations between categorical variables, we
used Pearson’s ×2 test and ×2 test for trend. Student’s t-test and Analysis of Variance (ANOVA) were applied for
the analysis of group differences within continuous variables. Correlation between
continuous variables was assessed with Pearson’s correlation coefficient. Due to multiple
significance tests made (n=50), the Bonferroni correction was applied to account for
the increase in type I error. So, a two sided p-value of less than 0.001 was considered
statistically significant. The Statistical Package for Social Sciences (IBM SPSS)
program, version 19.0 was used for statistical analysis.

Results

The response rate was 91% (191 out of 210 questionnaires). Sociodemographic characteristics
are presented in Table 1, information about health status is presented in Table 2 and their ability in Greek language in Table 3. Mean age of the study population was 37.4 years (10), while mean length of stay
in Greece was 76.8 months (33.1). Mean number of children was 1.5 (1.2). More than
half of the participants (56.5%) had health insurance coverage, 69.1% reported good/very
good health status, while 14.7% reported medication use for a chronic disease. The
ability of the participants to understand, speak, read and write Greek was 62.3%,
53.4%, 38.7% and 25.1% respectively.

Only 20.4% (n=39) of the participants reported that they had a good or very good degree
of knowledge about public health services in Greece, most of them (n=115, 60.2%) reported
that their knowledge was moderate and 19.4% (n=37) reported it as poor/very poor.

A considerable proportion of the participants (n=119, 62.3%), needed at least once
to use health services but they could not afford it, during the last year. The most
important reasons for that were high cost of health care (n=41, 34.5%), long waiting
times in hospital (n=15, 12.6%) and lack of free time (n=11, 9.2%).

Almost half of the participants (n=95, 49.7%) used public health services in the last
12 months in Greece. Among them, 56.8% (n=54) used emergency department services,
34.7% (n=33) visited physicians and 34.7% (n=33) visited dentists. Mean number of
visits in emergency department services, physicians and dentists was 0.4 (0.7), 0.4
(1.2) and 0.4 (1.2) respectively. Twenty-five (13.1%) immigrants were hospitalized
in the last 12 months in Greece with an average length of stay of 7.1 days (10.4).

There was not any statistically significant relationship between sociodemographic
characteristics and use of public health services. More than half of the participants
(n=101, 52.9%) reported that they had great difficulties in accessing health services,
29.8% (n=57) that they had moderate difficulties and 17.3% (n=33) that they had little
or no difficulties. Increased family monthly income was associated with decreased
difficulties in access to health services (×2 test for trend=32.1, p<0.001) (Table 5).

Table 5.Statistically significant relations between sociodemographic characteristics and access
in public health services

Among the most important problems concerning public health services in Greece were
long waiting times in hospitals (n=115, 60.2%), difficulties in communication with
health professionals (n=87, 45.5%), high cost of health care (n=74, 38.7%) and system’s
complexity (n=65, 34%).

Regarding their opinion about the quality of health care services provided to them,
only 20.4% (n=39) of the participants reported that health services in Greece were
good/very good, most of them (n=107, 56%) reported that health services were moderate
and 23.6% (n=45) reported that health services were poor/very poor.

Discussion

The findings of our study provide important information on the public health services
knowledge and utilization among immigrants in Greece. We found that 56.5% of participants
had health insurance coverage, a proportion relatively small compared to the natives
[13]. This may be explained by the fact that immigrants either are unemployed, informally
employed or undocumented (but were reluctant to state so) and therefore not able to
apply for health insurance. Other studies in different immigrant populations also
showed that they themselves as well as their children had less frequently health insurance
coverage in comparison to native populations [14-16]. Private insurance coverage is also rarer among immigrants than natives [17,18]. Sixty-nine percent of immigrants reported good/very good health status, a proportion
considered as satisfactory and explained by their young age. Previous studies conducted
in Madrid [19], New York [20] and Amsterdam [21] confirm this finding. One possible explanation may be the “Healthy Immigrant Effect”
since many studies have confirmed that immigrants have superior health status as compared
to the native population [22-24].

Immigrants report better self-reported health and functional health than their native
counterparts a phenomenon also been observed in many developed countries including
Canada, Australia, the US and UK [25-27].

However, only 20.4% of the participants reported adequate knowledge of public health
services in Greece in a good/very good degree while 52.9% reported having great difficulties
in accessing health services. Previous research suggests that limited knowledge about
health services decreases their utilization by immigrants [10,28,29].

Over half of the participants in the study (62.3%) expressed unmet needs regarding
health care services. The most important reasons according to the respondents were
long waiting times in hospitals, difficulties in communication with health professionals,
high cost of health care and system’s complexity, findings also confirmed by other
studies [30-37]. Access to care, is an essential element in achieving quality of life and growth,
a main objective in the Health 2020 strategic plan [38]. Apart from the present study, there is a growing body of research acknowledging
that immigrants face barriers in accessing health care services. Inaccessibility to
health care services for immigrants represents an important concern for all host countries
as it prevents newcomers from fully participating in society [22,39]. The delay in receiving the appropriate health care services or the unmet needs for
health care services, may lead to an increased demand for in-hospital or emergency
services having negative effects for the health outcome of the population, especially
for the middle and the low-income households and the vulnerable groups such as immigrants
which are the most affected [39-41]. Additionally, that may lead to higher health care expenditure in the long run, raising
serious concerns about the Greek health system sustainability especially during the
economic crisis. Policy makers should focus in increasing the efficiency of resource
allocation and the preservation of access to health services regardless of wealth,
education, age or ethnic group is imperative need.

Language barriers and miscommunication may result in the provision of suboptimal care
and have an impact to medicine/treatment adherence [42,43]. According to our findings only half of the study population (53.4%) reported good
or very good ability to speak while less than 39% reported good ability to read Greek.
Good ability to speak the language was strongly correlated with health services literacy.
This finding is in agreement with many studies since limited proficiency of the language
of the host country has been associated with increased waiting times and has been
identified as a significant obstacle in communication with health professionals, leading
in inappropriate use of health services [44-46]. Moreover, limited proficiency of the language spoken at the host country decreases
use of mental health services and immigrants’ satisfaction by the health services
[47-50].

Based on our findings, the empowerment and facilitation of the health care access
and provision for immigrants in Greece is necessary. Depending on the needs of the
migrant population, simple measures such as comprehensive information regarding the
available health services and the legal frame regarding the access for both lawfully
residents and undocumented immigrants, is an important step towards enabling better
access to needed services. Description of certain patient journeys in the system may
also be proven useful. Health care professionals should be better trained in order
to understand the special needs of the immigrants, the importance of accepting cultural
differences and the right of immigrants to qualitative services. Public health policy
measures related to appropriate coverage and adaptation of existing best practices
should be taken in order the system to be better able to respond to increasing numbers
of immigrants and assist in their social integration.

There are several limitations in our study. The study population was not a random
sample of immigrants in Greece, although an effort was to include the major groups
in proportions similar to those reported by recent statistical data. Additionally,
our information on the health status and medical conditions was based on self-report
and did not include objective measures, while the cross-sectional design of our study
could not capture temporal changes in the ability of immigrants to use and access
of health services. Also, data about utilization of health services were based on
self-assessments for the 12 months leading up to the survey and therefore this information
may be subject to recall bias. Larger scale studies including rural areas in Greece
should be conducted to better understand health services knowledge and utilization
among immigrants in Greece.

Conclusions

Despite the limitations, this study offers an insight into an extremely important
issue which constitutes subject of extensive discussions in Europe with a view to
formulate a common policy. Among the main findings of this study was that the knowledge
and use of public health services of immigrants was limited. Given the outbreak of
new epidemics (e.g. influenza virus, H1N1) and the resurgence of infectious diseases
which used to be in decline or elimination in Greece (e.g. tuberculosis and malaria),
the fact that little is known about the health of immigrants and their access to proper
health services, is concerning. Documentation regarding the immigrants’ health status,
the needs and access to and use of health services is a crucial area of research.
The findings of the study may contribute to tackle the phenomenon and stimulate further
research, since there may be a step further to control and tackle the phenomenon.
Co-ordinated action of governmental and nongovernmental organizations and researchers,
based on best practices may succeed to improve access of immigrants to health services.

Competing interests

All authors declared that they have no competing interests.

Authors’ contributions

GP: participated in the design of the study, performed the statistical analysis and
drafted the manuscript. SP: participated in the design of the study and performed
the statistical analysis. BT: participated in the design of the study TM: participated
in the design of the study and critical review the manuscript. KI: drafted the manuscript
SO: participated in the design of the study CG: critical review the manuscript KD:
participated in the design of the study and drafted the manuscript. All authors read
and approved the final manuscript.

Funding

This research has been co-financed by the European Union (European Social Fund-ESF)
and Greek national funds through the Operational Program “Education and Lifelong Learning”
of the National Strategic Reference Framework (NSRF)-Research Funding Program: THALIS-UOA,
MIS 377228.

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Kennedy S, McDonald JT, Biddle N: The healthy immigrant effect and immigrant selection: evidence from four countries. In Social and Economic Dimensions of an Aging Population Research Papers. Ontario: McMaster University; 2006:164.